Gladys Seroney- BScN, MScN

Maseno University
School of Nursing
Department of Community Health Nursing

INTRODUCTION

NATURAL HISTORY OF DISEASE:

STAGES OF HEALTH:
1) Prepathogenesis:
Disease has not yet occurred but the host is susceptible.
2) Pathogenesis:
Pre-clinical phase- no signs and symptoms
Clinical phase- signs and symptoms are present
3) Resolution:
There is recovery, disability or death of the host.
The course of a disease process from its onset to resolution is known as the “Natural history of
disease”

DISEASE PREVENTION AND INTERVENTION:

1) Primary intervention:
It aims at promoting health and preventing the disease process from occurring. This is
done in the prepathogenesis stage.
Intervention:
 Health education
 Immunization
 Chemoprophylaxis
 Ante-natal care and Post-natal care
 Personal hygiene
 Environmental sanitation

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  Exercise
 Proper nutrition
2) Secondary prevention:
The aim is to detect disease in its early stages before clinical signs and symptoms appear.
This helps to reduce or reverse the severity of the disease and to cure it.

Intervention:
 Screening programs e.g. Pap smear, regular BP checks, Check X-rays and sputum
smears for suspected TB or contacts
 Treatment using appropriate medications
 Referrals
 Disease surveillance
3) Tertiary prevention:
It is aimed at arresting the disease process, reduce disability and rehabilitate.
Intervention:
 Treatment of defaulters on TB
 ARV’s for HIV/AIDS patients
 Physiotherapy for patients with chronic bone and joint problems
 Training programs for the disabled
Diseases can be divided into a few large groups according to their main causes. Most of the
common diseases in Africa are due to infection by living organisms-viruses, bacteria, chlarnydiae,
rickettsiae, fungi, protozoa or metazoa. These are called communicable diseases because they
spread from person to person or from animals to people. Together with malnutrition, they are today
the major cause of illness in Africa.

The communicable diseases occur at all ages but are most serious in childhood due to intensive
exposure and poorly developed immunity. These diseases are to a great extent preventable. In
countries where they have been largely prevented, other conditions such as accidents and the
degenerative and malignant diseases, which occur mainly at an older age, have taken their place
and become the commonest. This process, usually called the epidemiological transition, is creating

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a situation in which communities, districts and countries continue to struggle with a lot of poverty-
related ill health (diarrhoeal diseases, parasite infestations, respiratory infections, immunisable
childhood infections, skin and eye infections, malnutrition) while at the same time facing a steady
increase of diabetes, cardiovascular disease, rheumatic conditions and cancer, all competing for
scarce diagnostic and therapeutic resources.

While this transition accelerates in different parts of Africa, new problems have appeared in the
form of so-called “emerging infectious diseases”. They are defined as infections that have
increased in incidence during the last couple of decades or threaten to increase in the near future.
Examples include viral, zoonotic and bacterial diseases such as ebola haemorrhagic fever, Lassa
fever and those caused by new multi-drug resistant strains of endemic microbes: Mycobacterium
tuberculosis, Staphylococcus aureus and Streptococcus pneumoniae. The reasons behind these
emerging infections are not well known, but likely factors include increased population density
and migration, ecological changes and deteriorating health infrastructure.

Communicable Diseases

Communicable diseases are very important in Africa because:

 Many of them are very common

 Some of them are serious and cause death disability
 Some of them cause widespread outbreaks of disease, that is epidemics
 Most of them are preventable by simple means
 Many are particularly serious ( an more common ) in infants and children

ORGANISMS AND AGENTS OF DISEASE

The living organisms that cause communicable diseases are of different sizes and sorts. The
largest, like tapeworms or the filariae, are visible to the naked eye. They are made up of many cells
and are called metazoa. Complicated but single- cell organisms, like malaria parasites and
amoebae, are called protozoa. They are smaller and can only be seen when magnified by a
microscope. Smaller still are bacteria which are simple, single cells best seen under a microscope
after they have been stained with dyes. Rickettsiae and chlamydiae are smaller and can only

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multiply within cells, Smallest of all are viruses which cannot even be seen with an ordinary
microscope.

PATTERNS OF COMMUNICABLE DISEASE

Different diseases are common in different places and at different times. To understand why this
happens, we need to consider the living organisms of disease, the agents, the people they infect
the hosts, and the soundings in which they live, the environment.

The agents need a suitable environment in which to grow and multiply and thus be able to spread
and infect other hosts. If they do not succeed in doing this, they die out. There is therefore a balance
between the agent, the host and the environment which can change and be made to change in
different ways.

Hosts (people) are affected by their environment. For example, they may live in a hot and wet
climate in which there are many mosquitoes. But people can also change this environment by
draining swamps, changing the vegetation and adding competing hosts such as animals. Similarly,
the environment can affect the agent, for example, the altitude and temperature for malaria.

When the balance between these three is constant, there will be a fairly steady number of people
getting sick all the time. When this happens, a disease is said to be endemic. Where the balance is
sifted in favour of the organism, for example when many non-immune children have been born in
an area since the last measles epidemic or there has been an influx of non-immune people through
migration, a large number of cases of measles may occur in a short time. This is called an
epidemic. When all the non-immune have had the disease, the number of new cases will again
decline. If the balance can be shifted against the agent, the disease will be controlled and the
number of cases will go down.

THE MANAGEMENT OF COMMUNICABLE DISEASES

The proper management of communicable diseases involves both trying to stop people getting
diseases (prevention) and looking after those who have them (case management including
treatment). The two are closely related and together amount to control. Doing one without the

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other is only doing half the job. To be able to prevent communicable disease, it is necessary to
understand the factors which affect the balance between the host, the agent, and the environment
and to know what can be done to tip the balance in favour of control.

Eradication, meaning total elimination of a disease, is theoretically possible but rarely feasible
and likely to be expensive, particularly in the final phase. It was accomplished in the case of
smallpox after a global WHO-coordinated campaign over many years with the last case seen in
rural Somalia in the mid 1980s, but this was possible thanks to certain circumstances which are
less favourable in the case of other diseases. A more practical approach is to examine critically the
host-agent-environment relationship in the cases of diseases badly in need of improved control and
then plan selective intervention to tip the balance in favour of the human host. This may include
improved nutrition in vulnerable groups, immunisation, improved drinking water supply,
sanitation and food hygiene, environmental interventions, insect vector control and health
education.

THE HOST AND INFECTION

Most of the communicable diseases in Africa have people as their main host. There are, however,
a few important animal infections which sometimes spread to humans. They are called zoonoses,
and particularly serious examples are rabies and plague.

When an organism infects a person, there are several stages to consider. The time between
infection and the appearance of symptoms and signs of illness is called the incubation period.
The shorter the incubation period, the more rapidly the disease can spread or die out in the
community. Infection with certain organisms nearly always leads to detectable symptoms and
signs—a clinical infection. Others are able to infect people without always producing obvious
symptoms or signs; these are called sub-clinical infections. This is important because people with
symptoms and signs are ill and therefore come for help from the medical services, or medical
workers can find them. But people with sub-clinical infections do not know they are infected and
hence a danger to other people. It is also very difficult to detect them in the general population
without special tests, these people are called carriers because they have a subclinical infection and
are carrying or excreting organisms which are dangerous for other people. This can occur during

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the incubation period (e.g., measles with a short incubation period, or HIV infection leading to
AIDS after a long period), or following recovery (e.g., typhoid).

People are susceptible to many diseases. They may have or develop resistance to some diseases.
The resistance of the human body is provided by its various defence mechanisms: the defensive
properties of the skin structure and special antibodies, antibacterial action of secretions (both
chemical and antibodies), white blood cells, and immunity. Immunity is due to special body cells
and to antibodies circulating in the blood Immunisation procedures are an artificial way to raise
people’s resistance to certain infections by giving them vaccines.

The reservoir of the infection is the animal or place in which a particular organism usually lives
and multiplies. For most of the important communicable diseases, humans are the main reservoirs.
For brucellosis, it is cattle; for rabies, wild animals; and for a few (e.g., tetanus), it is the soil. The
source of the infection is the animal or place from which the particular organism spreads to its new
host. The way in which an organism leaves the infected host or source and travels to a new
susceptible person is called the route of transmission. Each disease organism has particular routes
which play a large part in how these organisms spread in the community. For example, some
organisms are spread through water and food, while others are spread by vectors like mosquitoes
and snails.

The transmission cycle describes how an organism grows, multiplies, and spreads. In some cases,
humans may be the only host, in which case the infection spreads directly from person to person,
e.g., measles. In other cases, humans are the final host from whom the organism has no chance to
pass further, e.g., tetanus.

Source

The source of an infection can be infected person or animal or soil. People and animals may have
clinical disease, subclinical infection or be carriers. If there is a reservoir, it should be considered
with the source.

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Transmission

The main routes of transmission are:

 Direct contact (skin, mucous membrane, sexual),

 Vector,
 Faecal contamination of soil, food, and water which are ingested,
 Contact with animals and their products (e.g., biting),
 Airborne (inhalation),
 Transplacental (during pregnancy),
 Blood contact (injection. surgery, blood transfusion).

Susceptible host

A susceptible host is one with low resistance to the particular infection. Low resistance may be
due to:

 Not having met the organism before and therefore not having any immunity to it For
example, at the age of 6—12 months a child loses tie passive immunity against measles
which was acquired from the mother during pregnancy. When in contact with another child
who has measles, the child will develop the disease because of no immunity against
measles unless the child has had active immunization.
 Having another serious illness like AIDS at the same time; such people have a high risk
of developing tuberculosis.
 Malnutrition, which can make infections worse.

PRINCIPLES OF COMMUNICABLE DISEASE CONTROL

The aim of control is to tip the balance against the agent. This may be done by:

 Attacking the source,

 Interrupting the route of transmission,
 Protecting the host.

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 1. Attacking the source or reservoir

Treatment

If cases can be treated with drugs that destroy the organism, then fewer (or none) are available to
spread to new hosts. The effectiveness of treatment as a control measure depends on how many of
the cases in the country can be reached and whether the treatment affects the agent’s capacity to
reproduce (for example, chloroquine has no gametocidal action). Treatment is an important
method in the control of tuberculosis and leprosy and in most sexually transmitted diseases.

For treatment to be effective, subclinical cases and carriers must also be treated. However, special
efforts have to be made to find them first as they do not usually present with any apparent illness,
e.g., subclinical infections of cholera, or ankylostomiasis, or asymptomatic sexually transmitted
diseases.

Where a high percentage of the population are known to have a disease, it is sometimes advisable
to treat everybody, without checking whether individuals have the disease or not. This is called
mass treatment and has been used, for example, in the treatment of schistosomiasis in school
children.

Isolation

Isolation means that the person with the disease is not allowed to come into close contact with
other people except those who are providing care. Therefore, the organisms cannot spread.
Isolation is used to control highly infectious and serious conditions such as haemorrhagic viral
fevers (e.g., Marburg and Lassa fever). Isolation is difficult to enforce, however, and has several
disadvantages. In particular, people are frightened of being isolated and this stops them coming
for treatment; hence the spread of the disease increases.

Reservoir control

In those diseases that have their main reservoir in animals, mass treatment or chemoprophylaxis
or immunisation of the animals can be carried out, e.g., in brucellosis. Other ways include
separating humans from animals or killing the animals and so destroying the reservoir, e.g., plague,
rabies and hydatid disease.

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Notification

Although they do not directly affect the source, notifications are essential means of keeping watch
(surveillance) on the number of new cases and thereby monitoring the effectiveness of the control
programme. Notification means that you immediately inform the local health authorities (e.g., the
District Medical Officer) that you suspect a patient is suffering from an infectious disease. The
authorities can then take measures to have your suspicion confirmed and to prevent the disease
from spreading. Notification must be done immediately and by the most rapid means possible.
When you do not have access to a telephone, fax, e-mail or two-way radio it may be necessary to
send a messenger to the DMO’s office.

Some diseases spread so quickly that they need international control measures. These diseases will
be reported by the authorities to the World Health Organization (WHO). Such internationally
notifiable diseases are cholera, plague and yellow fever. In addition to these three diseases on the
international list, national ministries of health also require notification of certain diseases in their
own countries, eg., meningococcal meningitis and acute poliomyelitis.

2. Interrupting transmission

Environmental sanitation

Many organisms spread through contaminated food and water, particularly those that are
dependent on the faeco-oral route. Other diseases are spread through refuse and dirty living
conditions, The airborne diseases usually spread when housing is inadequate and people live in
crowded rooms.

Personal hygiene and behaviour change

Many careless or unhygienic personal habits help to spread some diseases, particularly the contact
diseases and those that may be spread by faecal contamination of hands, food, soil and water.
Changes in personal behaviour are often difficult to initiate (especially sexual behaviour) and
require an educational process as described in AMREF’s manual, Health Education.

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Vector control

Any organism that requires a vector, like a mosquito or snail, for its transmission cycle may be
affected if the vectors are killed off or reduced. Methods of vector control include altering the
environment so that it is unfavourable to the vector (draining swamps), using toxic substances
(larvicides) and using other living organisms that attack the vector-biological methods (e.g.,
introducing larvae- eating fish into water where the mosquito vectors of malaria are breeding).

Disinfection and sterilization

These methods aim at destroying the organism when it is in the environment, e.g., the use of
chlorine in wells, boiling of potentially contaminated food and sterilization of surgical instruments.

3. Protecting the host

Immunization

Immunization increases host resistance by strengthening the internal defences-. antibodies, killer
cells. It is one of the most effective methods of control for some communicable diseases.
immunization plays a critical role in the control of many communicable diseases in Africa. For
example, it was responsible for the worldwide control of smallpox. Other communicable diseases
in Africa which can be controlled through immunisation include measles, poliomyelitis, whooping
cough, diphtheria, tuberculosis and tetanus.

An Expanded Programme on Immunisation has been assisted throughout the world by WHO and
UNICEF. This programme has raised the coverage of immunisation in infants and children to
levels which in some areas are difficult to sustain due to serious resource limitations.

To be effective in control of a disease in a community, immunisations have to be given to a high

proportion of the people (at least 80 per cent coverage). The protective effect obtained when a high
proportion of the population has been immunised is called herd immunity. Herd immunity may be
produced when many people have a disease (active natural immunisation) and by giving
immunisations to most of a population (active artificial immunisation).

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Chemoprophylaxis

Drugs that protect the host may be used for suppressing malaria, and for preventing infection with
such diseases as plague, meningitis and tuberculosis.

Personal protection

The spread of some diseases may be limited by the use of barriers against infection, e.g., shoes to
prevent entry of hookworm from the soil, bednets and insect repellents to prevent mosquito bites.
These measures require health education for the community and individuals and access to the
appropriate devices at affordable cost.

Better nutrition

Malnourished children get infections more easily and suffer more severe complications (e.g.,
diarrhoea with dehydration). Also, infections are more common during famines when people tend
to crowd together for assistance making it easy for many communicable diseases to spread.

APPROACH TO OUTBREAKS OF DISEASE

An outbreak is the occurrence of a number of cases of a disease, known or suspected, that is larger
than expected for a given time and place. Even a single case may constitute an outbreak,

An outbreak of infectious disease may evolve quickly with the risk of spreading the disease within
the local population and extending the disease outside the local area. A decision to act rapidly to
manage an outbreak depends on:

 Severity of the disease,

 Risk of spread of the disease within the local population,
 Number of cases expected to occur,
 Risk of social and economic disruption,
 Danger of regional, national and international transmission.

Outbreaks of disease can be classified according to mode of spread (point source or propagation)
and major clinical presenting features. Such features can be fever alone, fever with rash, fever and
haemorrhage, fever and jaundice or fever and neurological or respiratory tract disease.

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Investigation, management and control

Investigation, management and control activities are carried out immediately and concurrently as
soon as an outbreak is reported. An investigative team must be established to work together and
consult on major findings and strategies. This team must include a clinician, laboratory technician,
public health expert and nurses. The team should:

 Verify the presence of the outbreak through communication with local people and medical
staff and by checking medical and laboratory records in health facilities.
 Confirm the nature of the disease through detailed examination of affected individuals
following standard procedures.
 Manage all cases according to standard treatment guidelines and as close to the site of the
outbreak as possible. Do not refer patients.
 Determine the extent of the outbreak-numbers of patients affected and the specific
population group affected.
 Determine the source and mode of transmission through examination of contacts and
sources.
 Determine areas and persons at risk.
 Control the epidemic by using appropriate strategies: cleaning and protecting water
sources, improving sanitation, treating contacts, immunisation, public health education.
 Communicate with the community and relevant authorities.
 Educate the community and train health workers to prevent future outbreaks and to ensure
a rapid and appropriate response in the future.
 Observe for surveillance after the epidemic has been controlled in order to monitor the
level of the disease in the population and detect a rise in the number of cases as early as
possible.

Surveillance is a measure of the success of the preventive strategies established in the community.
Surveillance can be active or passive. Active surveillance is planned, frequent, in-depth searches
for cases of selected diseases in the community. Passive is regular collection of statistics on
incidence at all levels of the health services.

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The role of the laboratory

The laboratory plays a major role in determining the cause of an epidemic and in planning and
executing control strategies. A laboratory technician or technologist is an essential component of
the investigative team. Joint decisions made by the investigative team should involve the
laboratory and include the likely cause of the epidemic (from the clinical picture), tests to be done
on-site, tests to be done at the laboratory base (if away from the site) and tests to be referred to a
central laboratory. Before starting laboratory investigations, a protective strategy must be
established given the infectious nature of the problem. The following must be considered:
Protective clothing, disinfectants, sterilising procedures, disposal procedures and transport of
specimens.

In almost all areas there are diseases which could be reduced by relatively simple measures. The
difficulty is to know how and where to begin. One of the most important starting points is the
understanding that something can be done. Too often, people are unaware that high morbidity and
mortality rates can be reduced. Much can be achieved both by preventive measures and by prompt
simple treatment, for instance, of malaria, diarrhoea, pneumonia, and other diseases. However,
without the understanding and active cooperation of individuals and communities, few disease
control programmes will succeed.

Before a communicable disease programme starts, it is best if the following can be done:

1. Study the problem in your area or community and know all you can about the disease.

Start with a survey to find out the extent and distribution of the disease and what people think and
do about it.This is called community diagnosis.

2. Prepare yourself for a programme.

Study the information collected. Work out with the health team what needs to be done and discuss
this with community leaders. Make sure that the necessary equipment, drugs, and transport are
available, and that the staff have the necessary training.

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3. Make a plan with your community

Make sure that the necessary understanding and motivation exist for adequate community
participation. Ensure that you have the support of other health workers, e.g., extension officers in
community development, information, education and water development.

4. Follow up.

Make a plan to record information. Measure what progress is made and then follow and compare
the situation with what it was before. This helps you to see what is being achieved, that is,
monitoring and evaluation.

APPLICATION OF COMMUNITY CONTROL MEASURES

The actual application of the control methods can be undertaken by different groups of people, and
the responsibility for them is best thought of at three levels: individuals and villages; dispensaries
and health centres; and district and other higher levels.

Individuals and villages

Individuals and groups of people at the village level are responsible for:

 Completing immunisation,
 Personal, household and food hygiene,
 Protective barriers—shoes, bednets,
 Chemoprophylaxis—malaria,
 Avoiding unprotected sexual contacts, using condoms,
 Protection of water supplies and boiling or filtering water,
 Building and using latrines,
 Rubbish collection and disposal,
 Vector control—clearing the surroundings, drainage,
 Avoiding bilharzial water,
 Eliminating rats and fleas,

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Health Centres

Health centre and dispensary staff should support and encourage community- based disease control
programmes and, with help from the District Health Management Team, also ensure:

 Increased immunisation coverage,

 Reservoir control,
 Larviciding, mollusciciding,
 Water protection and purification,
 Inspection of food supplies, markets and shops,
 Sanitary control of public toilets,
 Information, education and communication on health promotion and disease prevention,
 Notifying disease.

District, regional, and central ministry services

 Staff at these higher levels are responsible for:

 Mass immunisation campaigns,
 Mass chemotherapy,
 Vector control schemes,
 :Major water schemes,
 Mass media information programmes,
 Health legislation,
 Research into control methods,
 Famine relief/refugee camps,
 Emergency epidemiology and control teams,
 Continuing education of staff.

All these activities need to be supported by health education.

The best communicable disease programmes are those which involve the community. Thus, the
nearby dispensaries and health centres have a vital role to play in stimulating community activities
in their catchment areas.

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 First, arouse awareness; then provide the necessary technical support.

ANTIMICROBIAL RESISTANCE AND ITS CONTROL

Antimicrobial resistance is an increasing global problem. Widespread and irrational use of

antimicrobial drugs such as antibiotics contributes to the development and transmission of single-
and multi-drug resistant micro-organisms. Such organisms may cause Tb, shigellosis and
salmonella as well as staphyloccoccal, pneumococcal and sexually transmitted infections.
Developing countries and hospitals are considered the most effective reservoirs for resistance
genes and multi-resistant strains of micro-organisms.

As long as bacteria, parasites and other micro-organisms were highly sensitive to antimicrobials
(including antibiotics and antimalarials), the management of serious infections and the control of
epidemic outbreaks were relatively easy. This situation has been changing, and increasing
proportions of human infection are responding poorly to formerly effective drugs. Control of
severe infections in sub-Saharan Africa has to combine several methods in an integrated effort to
balance hygienic measures, environmental interventions, immunisation, nutritional improvement
and selective use of antibiotics,

Drug resistance is a result of proteins counteracting the effects of antimicrobials and produced
within each microbe. The ability to produce such proteins is genetically transmitted vertically from
one generation of microorganisms to the next and also directly between microbes. This ability
varies slightly from one individual microbe to another. When exposed to effective drugs, the more
sensitive organisms die while the least sensitive-the more resistant-survive and go on to multiply,
which means that the next generation consists of descendants of the most resistant organisms in
the parent generation. Such degrees of resistance occur particularly when drugs are taken in low
or inadequate amounts allowing large numbers of resistant pathogens to survive, for example,
when antibiotics commonly used in humans are ingested by domestic animals with the feed and
later consumed by humans with the meat. It also occurs when poor or poorly informed patients
take antibiotics in inadequate amounts or for too short a time. Under-use and excessive use of
antimicrobials are harmful.

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Roles of micro-organisms

Micro-organisms play important roles in our total ecology. Most of them are useful for
decomposing dead organic matter in the environment and digesting food in our intestines. Some
of them may cause disease in humans or animals when occurring in sufficient numbers, in the
wrong place or in an individual with an inadequate immune system. Protection may be possible
through immunisation, and control is helped with new and increasingly potent antibiotics.
However, resistance to new drugs develops quickly when they are widely used; hence, more
caution and discipline are necessary.

Multi-drug resistance is responsible for many unnecessary hospitalisations, increased drug costs
and premature deaths. The situation is particularly serious in low-income countries where the
burden of infection is extremely heavy.

Remedial action

Various remedial actions have been proposed. Basically, health workers can:

 Apply antibiotics and other antimicrobials selectively based on diagnosis, preferably

supported by laboratory results,
 Train and retrain prescribers individually or in small groups,
 Apply existing legislation regarding the sale of drugs,
 Restrict use of antibiotics livestock management,
 Improve domestic water supplies and the disposal of excreta and other waste,
 Develop antimicrobial drug formularies and prescribing policies, particularly in provincial
and district hospitals.

References

1. Basavanthappa, B.T. (2018). Community Health Nursing, (3rd Edition). New Delhi.
India: Jayee Brothers Medical Publishers.
2. Nordberg, E. (1999). Communicable Diseases, (3rd Edition). Nairobi. Kenya: African
Medical and Research Foundation
3. Wood, C. (2008). Community Health. 3 ED. Nairobi. Kenya: African Medical and
Research Foundation.

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